Chrysalis Application Form

Northern Lights Chrysalis Flight/Journey Application

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Northern Lights Chrysalis Flight/Journey Application

Chrysalis is a three-day experience for either teenagers in 10th through 12th grade or young adults ages 18-24 that provides an opportunity for spiritual growth and renewal through Christian fellowship. Chrysalis equips and challenges youth to develop their relationship with Christ and inspires participants to live their faith in their home, church, school and community.Chrysalis experiences for teenagers are called flights and Chrysalis experiences for young adults are called journeys. These experiences happen concurrently. Please check the box that corresponds with the experience you are applying for.

First Name

Last Name

Preferred Nickname (for nametag)

Address

Address 2

City

State

Zip Code

Email

Cell Phone

Gender

Age

Birth Date

T-Shirt Size

Church & Denomination Currently Attending

School (if applicable)

Present Grade (if applicable)

Other Christian or School Activities in which you are active

Have the Chrysalis Flight/Journey, share groups and hoots been explained to you?

Yes

No

Any dietary, medical (medication required at specific times of the day), mobility or other concerns that may affect your attendance at the Flight/Journey?

Please list any allergies

Briefly state why you want to attend the Chrysalis Flight/Journey and what you expect from it.

Parent / Guardian First Name

Parent / Guardian Last Name

Parent / Guardian Emergency Phone **********

If you are 18 years or older, click Yes to agree, in the event of an emergency, Northern Lights Chrysalis has my permission to secure the services of licensed medical professionals to provide the care necessary, including anesthesia, for my well being.

Yes

No

************ All of the above information is necessary for your proper placement in the Chrysalis Weekend. Please fill in all blanks. The cost of the weekend is $65.00 per person. We request a non-refundable $15.00 registration fee that should be given to your sponsor along with your completed application. The remaining amount will be collected at the Registrar’s table upon arrival. Please make checks payable to the Northern Lights Chrysalis Community. Full scholarships are available. This form is an application and its submittal does not guarantee acceptance. You may be placed on a waiting list since we only have a certain number of spaces available. Applicants will be notified of acceptance by mail several weeks before the Chrysalis Flight/Journey.

Applicant's Electronic Signature is clicking Yes - We need your ACTUAL signature when you arrive at the event.

Yes

No

To be filled out by the Parent/Guardian if participant under 18 years old:

Parent / Guardian's Electronic Signature is clicking Yes - We need your ACTUAL signature when you arrive at the event.

Yes

No

This Applicant has my permission to attend the Chrysalis weekend. In the event of an emergency and if I/we cannot be reached by phone, Northern Lights Chrysalis has permission to secure the services of licensed medical professionals to provide the care necessary, including anesthesia, for my child’s well-being.

When you click the SUBMIT button, you will receive an email of this completed form.

Find Us

Address 801 Park Ave Hamilton, OH 45013

About This Site

Sharing the Love of Jesus in the Mason, West Chester and Hamilton, Ohio areas. Walk to Emmaus Chrysalis Flights Kairos Prison Ministry